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a S c i T e c h n o l j o u r n a lResearch Article

Journal of Spine & Neurosurgery

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Panchal et al., J Spine Neurosurg 2013, 2:4http://dx.doi.org/10.4172/2325-9701.1000116

International Publisher of Science, Technology and Medicine

Using Titanium Mesh Cage and Anterior Cervical Plate for Cervical CorpectomiesRipul R. Panchal1*, Kee D. Kim1, Mark A. Krel1, John Lopez2, Kiarash Shahlaie1, and Matthew Bobinski1

AbstractObjective: After cervical corpectomy, numerous materials are available for interbody fusion. We report our experience with titanium mesh cage (TMC) with anterior cervical plate (ACP) for single and multi-level corpectomies for anterior cervical diseases.

Methods: Ninety-one consecutive cases (52 male, 39 female) that had undergone TMC with ACP at a single institution over a six-year period.

Results: Sixty-six patients (82.5%) had excellent (33.8%), good (30.0%) or satisfactory (18.7%) outcome using the Odom’s criteria. Fourteen patients (17.5%) were categorized as worsening of their symptoms at their last visit and 11 patients (12.1%) were lost to follow up (8 patients with autograft, 3 patients with allograft filled TMC). Significant effect of graft type on fusion status (χ2(9) = 18.771, p = 0.027) was identified. The fusion rate for patients with TMC filled with autograft was 81.3% (39 patients), allograft was 66.7% (12 patients) and for mixed was 57.1% (8 patients).

Conclusions: TMC filled with local autograft and ACP is a safe and effective surgical treatment for single and multi-level corpectomies at discretion of the surgeon in selected patient population.

KeywordsCervical corpectomy; Titanium mesh cage; Anterior cervical plate; Fusion

*Corresponding author: Ripul R. Panchal, Assistant Professor, Department of Neurological Surgery University of California, Davis Medical Center, 4860 Y Street, Suite 3740 , Sacramento, CA, USA 95817, Tel: 916-734-3102; Fax: 916-452-2580; E-mail: [email protected]

Received: April 12, 2013 Accepted: July 11, 2013 Published: July 15, 2013

There are myriad of materials for interbody fusion and reconstruction after anterior discectomy or corpectomy [2,10,14]. The traditional methods of cervical spinal fixation after corpectomy have been with allograft or autograft, usually fibular or iliac crest, supplemented with anterior plate fixation [4,8,12,15-18]. However, donor site morbidity, graft collapse, graft migration, or telescoping of the graft with subsequent pseudoarthrosis and kyphotic deformity has been reported with traditional methods [10,15,17-24]. As a result, materials including biocompatible osteoconductive polymer plastic [25], titanium tubular mesh cage [2,3,10,11,14,19,26], expandable cylindrical cage [27-29], and a telescopic anterior metal box plate spacer filled with bone graft [30] became available for stabilization and fusion. Reconstruction using titanium mesh cage (TMC) with an anterior cervical plate (ACP) is a safe and effective technique that offers immediate anterior column support and good fusion rates [2,9-11,19,20,26,31-34]. This study reports our experience with TMC with ACP for single and multi-level corpectomies for multiple pathologies (degenerative, trauma, neoplasm, congenital, and infection).

Methods The charts of 91 consecutive patients (52 male, 39 female) that

had undergone cervical corpectomy and fusion using TMC over a six-year period at a single institution were retrospectively reviewed with approval of institutional review board (Table 1). The mean age of the patient population was 51.8 years (range 16-81 years). The

AbbreviationsTMC: Titanium mesh cage; ACP: Anterior cervical plate

IntroductionSpondylosis is the most common disease affecting the adult cervical

spine. Controversy still exists over performing corpectomy versus discectomy for multilevel cervical disc disease [1,2]. When the spondylosis leads to spinal cord compression beyond the disc space, removal of the cervical vertebrae may be necessary to achieve adequate decompression [3-7]. Cervical corpectomy is a well-recognized treatment option for multilevel anterior compression of the cervical spinal cord [2,4,8-13]. The decision to perform a corpectomy should be based on degree, extent and location of cord compression, degree of cervical deformity, risk of mechanical failure and expected fusion rate [1].

Population n = 91

AgeMeanRange

51.816 - 81

SexMaleFemale

52 (42.9%)39 (57.1%)

EthnicityCaucasianLatinoAfrican AmericanAsianOther

60 (65.9%)9 (9.9%)7 (7.7%)3 (3.3%)

12 (13.2%)Clinical Presentation

PainMyelopathy Radiculopathy

54 (59.3%)29 (31.9%)

8 (8.8%)

PathologyDegenerativeTraumaNeoplasmCongenital (Klippel-Feil [1], OPLL [1], Deformity [4])Infection

60 (65.9%)11 (12.1%)11 (12.1%)

6 (6.6%)

3 (3.3%)Previous cervical surgery

NoneAnterior

ACDF Corpectomy

PosteriorBoth (Anterior and posterior)

69 (75.8%)12 (13.2%)

102

3 (3.3%)7 (7.7%)

Table 1: Demographics of Patient Population.

* OPLL = ossification of posterior longitudinal ligament; ACDF = anterior cervical discectomy and fusion

Citation: Panchal RR, Kim KD, Krel MA, Lopez J, Shahlaie K, et al. (2013) Using Titanium Mesh Cage and Anterior Cervical Plate for Cervical Corpectomies. J Spine Neurosurg 2:4.

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ethnic backgrounds included Caucasian (65.9%), Latino (9.9%), African American (7.7%), Asian (3.3%) and other minorities (13.2%). Although, the patients’ chief reasons for presentation were categorized into three types: pain (59.3%), myelopathy (31.9%) and radiculopathy (8.8%), most of the patients presented with some combination of all three types. In the majority of cases, patients presented with degenerative spinal disease (60 patients, 65.9%). Other pathologies included trauma (11 patients, 12.1%), neoplasm (11 patients (12.1%), and infection (3 patients, 3.3%). Of the 91 patients, 22 (24.1%) patients had already undergone some form of anterior (12 patients, 13.2%), posterior (3 patients, 3.3%) or both anterior and posterior (7 patients, 7.7%) surgical intervention previously.

Surgical “level” for corpectomy was defined by vertebral level and discectomy by disc level [1]. Titanium Pyramesh ovoid curved cage (10x14mm, 8 degree radius) (Sofamor-Danek, Memphis, TN) cut to an appropriate length was used for vertebral body reconstruction (Figure 1), packed usually with local autograft, allograft or a combination of the two based on enough autograft available or surgeon’s preference. A static anterior plating system (Atlantis by Medtronics, DEG by Blackstone, and Slim-Loc by Codman) were used at discretion of the senior author (KDK).

The cervical corpectomy procedure including the placement of a titanium mesh cage and anterior plate has been described [4,16,20,26]. Surgical approach, unless contraindicated, was through a transverse incision in a pre-existing skin crease usually on the left side of the neck so as to reduce the risk of injury to the recurrent laryngeal nerve. Fluoroscopy was used in all cases for localization and hardware placement. Neuro-monitoring was only rarely used in patients with severe stenosis and/or myelopathy. For patient that had previous anterior cervical surgery, the decision was made to approach from the same side as the previous surgery and those who reported recurrent laryngeal nerve injury, an otolaryngology evaluation was done. The corpectomy was performed to at least fit the largest diameter of the corpectomy cage (at least 15mm in diameter) and decompression included the resection of posterior longitudinal ligament to expose the ventral aspect of the thecal sac. The endplates prepared with a curret to remove the cartilaginous end plates from the bony endplates and curret was used to decorticate the bony endplates until slow bony bleeding was noted.

All patients were examined in clinic by the senior author (KDK). Static (antero-posterior and lateral) cervical spine X-rays were obtained at the one-month visit; dynamic imaging including flexion and extension views were performed at three months. Computerized

tomography with or without myelography and/or magnetic resonance imaging was pursued in subsequent visits only if there were new and/or persistent clinical issues. A patient was presumed to have bony fusion if there was no change in interspinous distance on dynamic radiographs as determined by an independent neuroradiologist (MB) [35]. Osseous trabeculae bridging across both the rostral and caudal ends of the graft were noted when easily visible, but were not a focus of the radiographic assessment. Pseudoarthrosis or “no fusion” was defined as evidence of interspinous distance ≥ 2mm and lack of trabeculae bridging the graft margins also determined by same neuroradiologist [16,35], otherwise considered incomplete or partial fusion. Subsidence of the cage was defined as 3mm or more migration of the cage into the adjacent endplate [36].

Clinical outcome was designated using the Odom criteria (Table 2) [37]. The observed complications were recorded and their correlation with fusion rate and clinical outcome was evaluated.

Statistical AnalysisData was compiled and coded in SPSS version 17.0 (IBM, New

York). Descriptive statistics including counts, ranges, and means were calculated for patient basic data including demographics, type of surgery, revision status, and type of surgical graft. For more detailed analysis and categorization of relative frequencies, cross tabulations were used. These cross tabulations included fusion status versus presenting pathology, clinical outcome versus presenting pathology, fusion status versus graft type, fusion status versus presence of pseudoarthrosis, and clinical outcome versus fusion status. To determine statistical significance, Chi-square values were calculated to compare the categorical variables in assessing the following: graft type’s effect on fusion status, presenting pathology’s effect on fusion status and clinical outcome, and fusion status’ effect on clinical outcome.

Results In the six-year duration, 1-level corpectomies were performed in

56 consecutive patients, 2-level in 27 consecutive patients, 3-level in 7 consecutive patients, and 4-level in on patient using the titanium mesh cage with anterior cervical plate (Table 3). The TMCs were filled with autograft in 56 (61.5%) of the cases, allograft in 21 (23.1% of the cases) or mixed in 14 (15.4%) of the cases. Twelve patients (13%) underwent single level corpectomy with an adjacent level discectomy resulting in a hybrid construct. Two cases (2.1%) involved revision of previous anterior cervical discectomy and instrumented fusion. In nineteen cases, anterior cases had supplementation with posterior instrumentation. Total of 6 patients (6.6%; 4 patients with 2-level corpectomy and 2 people with 3-lelvel corpectomy) underwent Halo brace post-operatively due surgeon discretion. There were eleven patients (12.1%) lost to follow up.

Figure 1: Titanium Pyramesh Cervical Cage –Ovoid (10x14x45mm), curved (8 degree radius) cage Sofamor-Danek, Memphis TN) (Right) and CT illustratinging TMC with ACP after 3-level corpectomy (Left).

Outcome Description

Excellent No complaints; able to carry out physical activities

Good Intermittent discomfort, able to carry out physical activities

Satisfactory Subjective improvement; physical activities significantly limited

Poor Symptoms and signs unchanged or worsened

Table 2: Odom’s Criteria [29].


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The average clinical follow up for these patients was 8.4 months, extending to 70 months (Table 4). However, the average radiographic follow-up was 5.61 months, extending to 70 months because when solid fusion on dynamic films was confirmed and the patient was clinically doing well, additional imaging was not performed. Sixty-six out of 80 patients (82.5%) had excellent (33.8%), good (30.0%) or satisfactory (18.7%) outcome using the Odom’s criteria. Fourteen patients (17.5%) were categorized as worsening of their symptoms at their last visit. No new cases of C5 motor root palsy were identified.

Our analysis revealed a significant effect of graft type on fusion status (χ2(9) = 18.771, p = 0.027). There were 11 patients (8 patients with autograft, 3 patients with allograft) lost to follow-up. The fusion rate for patients with TMC filled with autograft was 81.3% (39 patients), allograft was 66.7% (12 patients) and for mixed was 57.1%. Total of 59 patients (73.8%) were observed to have solid fusion at their last clinical follow up, 39 (66.1%) patients with autograft, 12 patients (20.3%) with allograft, and 8 patients (13.6%) with mixed graft used to fill the TMC cages (Table 4). Nineteen patients (23.8%; 9 patients with autograft, 6 patients with allograft and 4 patients with mix) had incomplete or partial fusion. Only two patients (2.1%) had no fusion and in both, TMC cages were filled with mix of both autograft and allograft.

Clinical outcome data was available for 80 patients (Table 4). Dysphagia was observed in 22.5% of the patients (13 patients, transient; 5 patients, permanent). Four of the five patients with permanent dysphagia had previous cervical spine surgery. Hoarseness was noted in only one patient that had blood dyscrasia leading the difficult dissection with postoperative hematoma. No new cases of wound infection were documented. Cerebrospinal fluid leak was observed in 3.3% (2 patients). Post-operative hematoma was noted in one patient. Implant migration including subsidence and implant failure including TMC subsidence was observed in 10% of population. Systemic complications ranging from urinary tract infection to cardiovascular event were observed in 16.3% (13 patients). Postoperative mortality related to surgery was observed in 1.3% (1 patient); however, six additional patients died due to their comorbidities.

The range of presenting pathologies included fracture, spondylotic disease, metastatic disease, anatomic deformity, and primary tumors. The most frequent presenting problem was spondylotic disease (63% of the cases in this study). The type of presenting pathology, however, did not have a significant effect on ultimate fusion status (χ2(15) = 9.575, p = 0.846). Despite the lack of significant effect of presenting pathology on fusion status, it nearly reached significance in its effect of clinical outcome (χ2(30) = 43.147, p = 0.057). All patients with

only anatomical deformity had improved clinical outcome. Patients with degenerative disease and trauma had the highest percentage of non-improvement. Lastly, there was no significant effect of fusion status on clinical outcome (χ2(9) = 17.662, p = 0.478).

DiscussionCervical Corpectomy is a well-recognized treatment option for

multilevel anterior compression of the cervical spinal cord [2,4,8-13,38,39]. Overall, our study shows reconstruction using titanium mesh cage (TMC) with a static anterior cervical plate (ACP) is a safe and effective technique that offers immediate structural support and good fusion rates for single and multi-level corpectomies with good clinical results (Figures 2-4).

Use of local autograft from the corpectomy site may be sufficient to achieving solid fusion when TMC with ACP is used (p = 0.027). Total of 59 patients (73.8%) were observed to have solid fusion at their last clinical follow up, 39 patients with autograft, 12 patients with allograft, and 8 patients with mixed graft used to fill the TMC (Table 4). Nineteen patients (23.8%; 9 patients with autograft, 6 patients with allograft and 4 patients with mix) had incomplete or partial fusion. Only two patients (2.1%) had no fusion and in both

Level of Corpectomies Patients (%)

1234

56 (61.5%)27 (29.7%)

7 (7.7%)1 (1.1%)

RevisionHybrid constructPosterior procedures

21219

GraftAutograftAllograftMixed

56 (61.5 %)21 (23.1%)14 (15.4%)

Table 3: Summaries of Surgeries Performed and Grafts Used.

Follow upAverageLast Imaging studyLost to follow up

Average (range or %)8.44 mo (0 – 70, σ = 10.27)5.61 mo (0 – 70, σ = 9.45)

11 patientsClinical Outcome (Odom Criteria)

ExcellentGoodSatisfactoryPoor

Number of patients (%)27 (33.8.%)24 (30.0%)15 (18.7%)14 (17.5%)

(# levels = #pt)(1=12;2=11,3=4)

(1=20,2=4)(1=4,2=9,3=1,4=1)

(1=12;2=2)

Fusion Status per type of graft

Solid FusionAutograftAllograftMixed

Incomplete/partial fusion

AutograftAllograftMixed

No fusionAutograftAllograftMixed

(χ2(9) = 18.771, p = 0.027)

59 (73.8 %)39128

19 (23.8)964

2 (2.5%)002

(1=21,2=15,3=3,4=1)(1=6,2=5,3=1)

(1=4,2=4)

(1=8,2=1)(1=4,2=1)

(1=4)

(1=1,3=1)

ComplicationsMorbidity

DysphagiaTransientPermanentPrevious surgeryDysphoniaTransientPermanent Hardware failureCage SubsidenceInfectionsCSF leakPostoperative hematomaSystemic

MortalitySurgery relatedNon-surgery related

Number of Patients

18 (22.5%)1354

1(1.3%)01

8 (10%)30

2 (3.3%)1(1.3%)

13 (16.3%)7 (8.75%)

16

(1=1,2=7,3=4,4=1)(1=2,2=3)

(1=4)

(2=1)(1=2,2=6)

(2=3)

(3=1,4=1)(2=1)

(1=5,2=1,3=1)

(3=1)(1=5,2=1)

Table 4: Clinical outcome of cervical corpectomy and reconstruction with TMC and ACP.


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patients, TMC was filled with mix of both autograft and allograft. The reported fusion rates are highly variable in the literature, ranging from 65 to 100% [10,16,18,40].

Mayr et al. reviewed 261 patients that underwent anterior cervical corpectomy with allograft fibula strut and anterior plating [16]. They reported 86.6% fusion rate for their series, which mainly consisted of single level (133) and two level (96) corpectomies. They found this procedure to be an effective means of achieving spinal decompression and stabilization in cases of anterior cervical disease. Additionally,

they provide a table of published series of patients that underwent corpectomy from 1976 to their series in 2002 comprising 22 articles and 1046 patients. All studies they list used autologous iliac bone graft, allograft fibula or autograft fibula. Thirteen studies listed used plates for at least some of their patients. The majority of studies involved the use of autologous bone without a plate. No significant conclusions can be drawn from the studies as a whole given the great variation in materials, outcome measures, and techniques. Nonetheless, Mayr et al. noted that overall fusion rates are highest in studies that use both autograft bone and anterior plating. In our study, the fusion rate

Figure 2: Lateral neutral cervical radiograph (A) immediate postoperative, and flexion (B), neutral (C), and extension (D) cervical radiographs at 30-month follow up with solid fusion after a single level corpectomy and fusion with TMC with autograft, and APC for traumatic C7 burst fracture.

Figure 3: Lateral neutral cervical radiograph (A) immediate postoperative, and flexion (B), neutral (C), and extension (D) cervical radiographs at 11-month follow up with solid fusion after a two-level corpectomy and fusion with TMC with autograft, and APC for cervical spondylotic myelopathy.

Figure 4: Lateral neutral cervical radiograph (A) immediate postoperative, and flexion (B), neutral (C), and extension (D) cervical radiographs at 1-year follow up with solid fusion after a three-level corpectomy and fusion with TMC with autograft, and APC for cervical spondylotic myelopathy.


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for patients with TMC filled with autograft was significantly higher (81.3%), compared to TMC filled with allograft (66.7%) and mixed (57.1%). Local autograft provides an effective and better option for filling TMC cages for achieving fusion with ACP. It obviates the need for harvesting iliac bone and risk of disease transmission with acceptable fusion rates [16,18,20].

However, no significant effect of fusion status on clinical outcome was observed (p = 0.478). Sixty-six patients (82.5%) had excellent (33.8%), good (30.0%) and satisfactory (18.7%) outcome using the Odom’s criteria. Fourteen patients (17.5%) were categorized as worsening of their symptoms at their last visit. The presenting pathology does nearly reach significance in its effect on clinical outcome (p = 0.057). As expected, all patients with only anatomical deformity had improved clinical outcome. Patients with degenerative disease and trauma had the highest percentage of non-improvement. The patients with degenerative disease or trauma tend to be much worse on neurologic presentation compared to patients with anatomical deformity requiring anterior cervical corpectomy. The most frequent presenting problem was spondylotic disease (63% in our study) and others included fractures, metastatic disease, anatomic deformity, and primary tumors, and infection; however, no significant effect on the fusion status (p = 0.846). Hence, we conclude that TMC with ACP is a versatile technique that can be utilized in variety of diseases requiring anterior cervical corpectomy for spinal cord decompression [39].

Daubs retrospectively reported his experience with 1-, 2- and 3-level cervical corpectomies reconstructed with TMC and ACP using local autograft in 27 patients [41]. He found a high early failure rate (75%) after reconstruction of multilevel corpectomies. The failure rate for the 1-level corpectomy group was (6%). He argues that posterior fusion and instrumentation should be considered when using this technique for multilevel reconstructions [41]. In nineteen (20.6%) of our patients, decision was made to supplement anterior surgery with posterior construct based on the quality of the patient’s bone, revision surgery with severe deformity or more than two levels of corpectomy. In our case series, we recorded implant failure in 8 (10%) of the patients with three cases of subsidence. Thus, when the vertebral body is noted to be “soft” intraoperatively, posterior instrumentation is recommended. TMC that was used in this series did not have endcaps. Like Narotam et al., we believe that better early stabilization and fusion can be achieved by not using endcaps and allowing the cage ends to “bite” into the adjacent vertebral bodies[19]. Yet, it is important to realize the potentially increased risk for subsidence without the use of endcaps. It is of the utmost importance to preserve the integrity of the endplates; particularly where the cage ends will be in contact with it. Thus, the surgeon must be especially aware of this possibility when decorticating the endplate in the process of tailoring the TMC for insertion. Excessive endplate decortication may result in suboptimal placement leading to subsidence and loss of lordosis [28]. A pre-contoured cage may also be beneficial in long-constructs (two or more levels) to preserve or restore lordosis thereby promoting long-term construct stability. More importantly, the TMC should be cut to an appropriate size to have a snug fit into the corpectomy site. An oversized or undersized cage placement may lead to hardware failure (cage subsidence or kicking out) or kyphotic deformity, respectively. Clinically, oversized cages lead to facet joint distraction that may lead to post-operative neck pain and possibly C5 motor root palsy.

The disadvantages of TMCs include cost, difficulty in assessing

fusion radiographically, difficulty in revision surgery, stress shielding and the potential for soft tissue injury [19,42]. Cost, however, may not be significantly different if increased morbidity and longer hospital stay associated with iliac crest autograft harvesting is taken into account [19,31].

The use of an anterior plate also offers the advantage of immediate stability, increased fusion rates and less of a need for postoperative rigid immobilization [16]. Most authors in the literature have required their patients to wear a postoperative orthosis, such as a hard collar. Dorai et al. [10] notably did not require their patients to wear any orthosis postoperatively and they still reported a 97.5% fusion rate. Like most surgeons, we believe that when proper cervical instrumentation has been placed, it is unnecessary for more aggressive bracing such as a Minerva vest or halo [4,16]. However, in rare patients who we believe will not be compliant with wearing a cervical collar or who were redo multilevel operations with osteopenic bone, a halo vest is placed to ensure rigid immobilization for bony fusion as well as supplementation with posterior instrumentation.

Like any surgical technique complications may arise (Table 4). Total of 14 patients had poor outcome. 6 patients died due to their comorbidities (3 patients with cancer, 4 patients with severe trauma). One patient died after developing urosepsis postoperatively due to Foley catheter. Two patients reported worsening of pain where managed non-surgically. No evidence of pseudoarthrosis was noted in these patients. Overall, 18 patients (22.5%) reported transient dysphagia, which for thirteen patients resolved at their last follow up visit. Four of the patients with permanent dysphagia had previous history of surgery leading to longer dissection time and in turn longer retraction time. Similarly the remaining patient with permanent dysphagia was a patient diagnosed with blood discrasia postoperatively. This same patient had undergone significant intraoperative retraction for hemostasis and postoperative course was complicated by dysphagia, hoarseness and postoperative epidural hematoma for which patient was taken back to surgery. The duration of retraction and cervical structure manipulation may have lead to postoperative dysphagia and dysphonia.

We acknowledge the limitations of this report, including the retrospective nature of the study’s design with inherent heterogeneity and the lack of consistent and long-term follow-up using standardized clinical and radiographic outcome measures. Regardless, our study documents that anterior decompressive surgery with TMC filled with autograft provides overall good clinical outcome compared to the natural history of severe cervical spondylosis and other anterior pathology [12,38,39,43]. Kalfas noted a rate of clinical improvement in myelopathy after decompression to be between 73 to 100% of patients in his review of cervical corpectomy [4]. Irrespective of reported rates of improvement, Fraser and Härtl argue that it is impossible to conduct a statistical analysis of clinical outcomes due to the diversity of outcome measures used in the literature [1]. Many studies, for example, do not include known factors that affect fusion rates such as age, smoking status, and comorbidities. Consequently, additional studies are needed to fully evaluate the clinical outcomes of the many different methods and materials used in cervical corpectomy. These new studies, however, will need the standardization of clinical outcome measures and also fusion evaluation techniques. In addition, the radiographic measurements such as cervical curvature, loss of correction and subsidence may be beneficial. The type of graft and instrumentation used should also be


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reported. Our study revealed that the use of TMC filled local autograft with ACP is an effective technique to early stabilization, good fusion rates, and clinical outcomes in multiple anterior cervical pathologies requiring corpectomy.

ConclusionTitanium mesh cage (TMC) filled with local autograft and

anterior cervical plate technique provides a safe and effective way of providing immediate anterior column support and good fusion rates for single and multi-level corpectomies without significant hardware complication. Posterior supplementation should be considered for greater than two level corpectomies as well as based on the clinical and radiographic findings at the discretion of the surgeon. More prospective studies are needed to better delineate the most effective and long-term treatment for individual anterior disease and clinical outcome.Acknowledgements

The authors would like to thank David Suh with gathering the patient data for analysis.

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Author Affiliation Top

1Department of Neurological Surgery, Department of Radiology, University of California-Davis Medical Center, Sacramento, California2St. Mary’s Hospital, Grand Junction, Colorado, USA

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